Provider Demographics
NPI:1952863078
Name:KENNEDY, JESSICA RENE'
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENE'
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9534 W COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-7828
Mailing Address - Country:US
Mailing Address - Phone:405-880-5944
Mailing Address - Fax:
Practice Address - Street 1:7125 S BRADEN AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6302
Practice Address - Country:US
Practice Address - Phone:918-481-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK87596363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics